Preferences for continuing education through existing electronic access for Australian Nurse Practitioners and its implication in prescribing potential
Article Outline
- Summary
- Introduction
- Nurse Practitioners and continuing education
- Method
- Ethical considerations
- Survey results
- Discussion
- Limitations
- Conclusion
- References
- Copyright
Summary
Background
Little is known about Australian Nurse Practitioners (NPs) perceptions of the importance of continuing education (CE), their preferred methods to undertake CE in relation to prescribing practices or their access to electronic resources at work. Nurse Practitioner access to computerised technology may increase their provision of resources, provide point of care technology, and increase opportunities to participate in CE.
Purpose
This paper aims to explore Australian NP preferences for continuing education and NP access to electronic mediums that may increase CE opportunities.
Methods
A self-administered online survey was completed by 68 NPs from across Australia.
Results
The majority of respondents (93%) viewed CE to be very important and preferred methods of continuing education included receipt of information by email, and interactive online case studies. Respondents working in metropolitan areas had increased access to high speed Internet in comparison to NPs working in rural or remote areas, although this did not reach statistical significance (88% vs. 69%, p
=0.07). Significantly more NPs working in metropolitan areas had access to a Personal Digital Assistant (PDA) than NPs working in rural or remote areas (44% vs. 6%, p=0.003).
Conclusion
This is the first national survey to report preference for CE and access to technology of NPs in Australia. Electronic technology can provide programmed support such as online learning and resources through computers and PDAs to maximise NP prescribing potential.
Keywords: Nurse Practitioner, Continuing education, Point of care technology, Personal Digital Assistants, Elearning
Introduction
The NP role in Australia was introduced in 1998 and as of mid 2007 there were approximately 230 NPs nationally (Della et al., 2007). Similarly to the United States (US), where legislation authorising NPs was passed over forty years ago, Australian NPs have advanced and extended nursing roles and are practicing in a wide range of specialities including emergency, mental health, and palliative care. The development of the NP role in the US has been accompanied by positive research findings in studies of NP practice (Phillips, 2007, Towers, 2005). The NP role in the US has progressed to encompass a wide range of improving services (Phillips, 2007). Most prominent in this development is the authorisation of prescriptive authority where to date US NPs have the authority to prescribe independently in 27 US states, and the authority to prescribe within a collaborative agreement with a physician in the remaining 23 states (Plonczynski, Oldenburg, & Buck, 2003). Whilst Australian NPs have gained prescriptive authority in all states and territories, except the Northern Territory where this legislation is under review, their ability to prescribe is hindered by a requirement to work within restrictive protocols and a lack of Commonwealth Government funding through the pharmaceutical benefits scheme (PBS) (Cashin, 2007). It has been suggested in literature that further barriers to prescriptive practice include difficulties in the availability of and access to appropriate continuing education, resources and clinical support as outlined below.
Nurse Practitioners and continuing education
Internationally, studies have found an association between the prescribing frequencies of nurse prescribers and their engagement in continuing education. Studies conducted in the United Kingdom (UK) reported a low uptake of prescribing practices amongst qualified-independent prescribers and identified that approximately only half of the samples reported engaging in formal CE (Courtenay et al., 2007, Latter et al., 2007). In a qualitative study conducted by Latter et al. (2007) of 202 nurse prescribers, a significant proportion (95%) of respondents reported engaging in self-directed CE. However only 50% reported engaging in formal CE. Similarly, Courtenay et al. (2007) surveyed a convenience sample of almost 1200 qualified-independent nurse prescribers that represented over 25% of UK registered nurse prescribers. The authors reported that only 58% of respondents indicated undertaking continuing professional development (CPD) since commencing prescribing and 32% reported being unable to access CPD.
A US study by Goolsby (2005) found high rates of prescribing amongst NPs to be associated with the uptake of CE activities. A survey undertaken by the American Academy of Nurse Practitioners (AANP) in 2004 collected data on the prescribing patterns of a large sample (16,062) of practicing NPs representing all 50 states and the District of Columbia. This survey found a high number (over 90%) of NPs continuing to prescribe after obtaining prescribing authority than was found in the UK studies. It is of note that 87% of respondents indicated being actively involved in continuing education. It would appear plausible that participation in CE may be associated with prescribing behaviour. The different contexts limit the certainty however of such a tentative claim.
Nurse Practitioner participation in CE may potentially be increased through the availability of electronic technology where web-based learning and distance education courses could be completed online. In addition to CE such technology may provide an effective source of information to NPs at the point of care. However, access to a computer with appropriate Internet connection is required in addition to NP confidence in using such sources. In conjunction with the digital revolution international research has focused on the use of PDAs by nurses as both an educational and resource tool (see for example, Davenport, 2004, Koeniger-Donohue, 2008). A Personal Digital Assistant is a handheld computer that may be beneficial for providing NPs with updates and point of care technology. The use of PDAs can allow NPs to store and access up-to-date reference material, including detailed drug information, that is available at the point of care in one's hand, saving time for NPs and decreasing the risk of human error and improving decision making (Krauskopf and Wyatt, 2006, Michael, 2007).
Little is known about Australian NPs perceptions of the importance of CE, their preferred methods to undertake CE in relation to prescribing practices or their access to electronic resources at work. This paper aims to explore Australian NP preferences for continuing education and NP access to electronic mediums that may increase CE opportunities.
Method
In 2007, a total of almost 100 NPs, NP candidates, educators in NP courses and managers of NP services participated in focus groups designed to discern the shape of NP prescribing behaviours, enablers and inhibitors. Thematic analysis of the focus group data, plus a comprehensive review of published and unpublished literature, was used to inform the content of a national online survey.
The electronic survey was available for a 2-week period in November 2007 via the National Prescribing Service and Australian Nurse Practitioner Association (ANPA) websites. Invitations to complete the survey were sent to all ANPA members and all participants in the original focus groups. In addition the survey was advertised in specialty newsletters and at relevant professional conferences.
Data analysis
Data were analysed using the program SPSS version 14.0 for Windows. Participant characteristics and outcome data are reported as raw data. Differences between groups were analysed using chi-square test (χ2) for categorical data.
Ethical considerations
Ethical approval was received from the Charles Darwin University Human Research Ethics Committee.
Survey results
Characteristics and demographics of respondents
A total of 68 authorised NPs participated in the survey. The sample represents 30% of Australian authorised NPs. The sample characteristics are shown in Table 1. Seventy percent of the sample was female and the majority of participants were practicing in nursing for more than 21 years. There was participant representation from every state and territory, with 56% of participating authorised NPs located in New South Wales. Three quarters of participants practiced in metropolitan areas and the majority (94%) in the public sector. Over 30 specialty areas of practice were identified by respondents. The largest speciality group with respondents was emergency care (23%).
Table 1. Characteristics of study participants (n=68).
| Number | ||
|---|---|---|
| Age in years mean (S.D.) | 47 | 8 |
| Female | 53 | 78% |
| Years practicing as an RN | ||
| <5 years | 0 | |
| 5–10 years | 3 | 4% |
| 11–25 years | 7 | 10% |
| 16–20 years | 10 | 15% |
| 21–25 years | 14 | 21% |
| >25 years | 34 | 50% |
| Location of practice | ||
| Metro | 52 | 76% |
| Rural | 12 | 18% |
| Remote | 4 | 6% |
| Practicing in public sector | 64 | 94% |
| Practicing in private sector | 4 | 6% |
| Jurisdiction of NP authorisation | ||
| New South Wales | 36 | 53% |
| Australian Capital Territory | 6 | 9% |
| Northern Territory | 1 | 2% |
| Queensland | 7 | 10% |
| South Australia | 5 | 7% |
| Victoria | 8 | 12% |
| Western Australia | 5 | 7.5% |
Importance of continuing education
Participants were surveyed on the importance of CE in relation to medication updates and legislative requirements for prescribing. The responses are presented in Table 2. The majority of participants (93%) considered CE on medication updates very important with the remainder rating it moderately important. Likewise, CE related to legislative requirements for prescribing was rated as very important for 87% of respondents (Table 2).
Table 2. Importance of continuing education and preferred methods.
| All respondents n=68 | Metro n=52 | Rural and remote n=16 | Metro vs. others | |
|---|---|---|---|---|
| N (%) | N (%) | N (%) | p* | |
| Importance of continuing education in relation medication updates | ||||
| Very important | 63 (93) | 49 (94) | 14 (88) | |
| Important | 5 (7) | 3 (6) | 2 (12) | 0.36 |
| Importance of continuing education in relation to legislative requirements | ||||
| Very important | 59 (87) | 46 (88) | 13 (81) | |
| Important | 9 (13) | 6 (12) | 3 (19) | 0.57 |
| Preferred methods of continuing education | ||||
| Email | 63 (93) | 47 (90) | 16 (100) | 0.65 |
| Conference workshops | 61 (90) | 46 (88) | 15 (94) | 0.45 |
| Interactive online case studies/tutorials | 60 (88) | 46 (88) | 14 (88) | 0.06 |
| Downloadable print packages | 60 (88) | 46 (88) | 14 (88) | 0.47 |
| Interactive modules on CD | 59 (87) | 45 (86) | 14 (87) | 0.88 |
| Face to face lectures/education evenings | 58 (85) | 46 (88) | 12 (75) | 0.31 |
| Online video presentations | 56 (82) | 42 (81) | 14 (88) | 0.90 |
| Download case studies/quizzes for PDA | 46 (68) | 34 (65) | 12 (75) | 0.76 |
| Online discussion groups | 42 (62) | 36 (69) | 6 (37) | 0.13 |
| Downloadable audio files (e.g. MP3) | 42 (62) | 33 (63) | 9 (56) | 0.91 |
*Between group comparison chi-square test (χ2). |
Preferred methods of continuing education
Respondents were asked to identify their preferred methods for continuing their education. The most desirable sources of continuing education included information by email (93% of participants), followed by conference workshops (90%), interactive online case studies (88%), downloadable print packages (88%), interactive CD modules (87%), face to face lectures/ workshops (85%) and online video presentations (82%). Least desirable methods included downloadable case studies for PDA's, online discussion groups and downloadable audio files (Table 2).
Access to electronic resources
Participants were questioned on their access to electronic resources with Internet access whilst at work. The majority of respondents (84%) reported having access to their own work computer with Internet access whilst at work. However, NP's practicing in the metropolitan setting were more likely to have broadband/ network access at work compared to rural and remote practitioners (88% vs. 69%), although this did not reach statistical significance (χ2: p=0.07). Additionally, participants were questioned on whether they “owned” a PDA. Over one third (35%) of NPs identified owning a PDA. Nurse Practitioners practicing in the metropolitan setting were more likely to report having a PDA compared to rural or remote NPs (44% vs. 6%, χ2: p=0.003).
Discussion
The results from this study indicated that the majority of NPs (94%) viewed CE to be very important. This is comparable to the sentiment underpinning the result in the US study by Goolsby (2005) in which 87% of NP respondents indicated being actively involved in CE. Despite a significantly higher amount of NPs in metropolitan areas owning a PDA, there was no difference between metropolitan and non-metropolitan NP's preference for receiving CE via PDAs. Email was identified as the most popular potential source of continuing education by 93% of respondents. This is congruent with the high number of NPs with Internet access participating in the survey (84%). These results are supported by the findings from a survey of 4330 members of the Australian Nursing Federation, where it was identified that 80% of RNs level 3 and above had sole access to a computer, and the level of experience and confidence with email was rated high (Eley, Fallon, Soar, Buikstra, & Hegney, 2008).
Electronic technology in addition to increasing opportunities for NPs to participate in CE activities may also provide an effective source of information to NPs at the point of care. Availability of evidence-based resources at the point of care would enable NPs to access the best available clinical content when making prescribing decisions (Chaiken, 2001, Chapman, 2007). Resources available at point of care for Australian NPs may include electronic versions of the Australian Medicines Handbook and National Prescribing Service resources. Other resources may potentially include access to prescribing software such as that available to general practitioners. However on exploration of Internet access at work, whilst the majority of NPs practicing in metropolitan areas (88%) had access to broadband or network Internet, only 69% of NPs working in rural or remote areas had this access. It is imperative that rural and remote area NPs have access to an appropriate Internet connection in order to provide an alternative to face-to-face methods of CE.
Nurse Practitioners practicing in metropolitan areas were significantly more likely to own a PDA. Findings from the Australian Nursing Federation Survey of 4330 assistants in nursing, enrolled nurses and registered nurses levels 1–5, of which NPs accounted for less than 5.9% of the total sample, identified that only 3% respondents had ever used a PDA (Eley et al., 2008). The results from our sample therefore suggest that NPs are more likely to have access to a PDA than registered nurses and highlight at this early stage the potential for computerised support systems to be effectively integrated into NP prescribing practice. In Australia, the potential benefits of PDAs have been recognised in the state of Western Australia (WA). In 2006 NP students in WA were given PDAs as part of a pilot study with the aim of facilitating the students’ ability to become leaders with the utilisation of technology in support of improved patient care and appropriate clinical communication (Michael, 2007). The trial was successfully implemented with the outcome resulting in the integration of PDAs into the student NP curriculum by 2008. Whilst it has been suggested that PDAs may benefit NPs by enabling point of care technology and improving educational experiences and access to resources, it has been highlighted that many NPs may be phobic of using PDAs due to the beliefs that patient data may be easily lost potentially breaching confidentiality, the perceived unaffordable cost and fear of inaccurate information (Davenport, 2004, Koeniger-Donohue, 2008, Krauskopf and Wyatt, 2006). Whilst issues relating to confidentiality may directly not affect the use a PDA for CE purposes it is unlikely that one would solely decide to incorporate a PDA into their practice for CE purposes only. It is of note that in this study the use of PDAs in continuing education was the least preferred potential source of continuing education (68%), with the exception of online discussion groups and downloadable audio files (62%). It has been suggested that PDA phobias could be overcome by incorporating simple, practical strategies such as synchronisation of PDA with desktop, taking responsible security measures and accessing Web sites that are dedicated to healthcare-related PDA applications (Krauskopf & Wyatt, 2006), and through online education programmes for NPs (Michael, 2007).
Limitations
The results of this survey must be interpreted in light of a few limitations. Despite multiple methods of advertisement of the survey (i.e. flyers, conferences, etc.), the completion of the survey was online which may have limited the ability of some NPs without computer access (either at home or at work) to participate. Additionally, respondents represented 30% of authorised NPs at the time of survey (Della et al., 2007), which may limit generalisation of the findings to all Australian NPs. It is also acknowledged that the sample of rural and remote respondents is small which may have limited the ability to detect differences between metro and non-metro responses.
Conclusion
Nurse prescribers internationally have experienced a number of economic and political barriers that limit their ability to utilise prescriptive authorisation. Electronic technology can provide programmed support such as online learning and resources through computers and PDAs to maximise prescribing potential. Such programmes will be valuable to aid NP access to up-to-date information and potentially contribute to the promotion of confident and effective NP prescribing.
References
- . Issues and challenges in advancing the nurse practitioner role. Collegian. 2007;14(4):4–5
- . Evidence-based medicine: A tool at the point of care. Nursing Economics. 2001;19(5):234–235
- . Developing decision support systems for nurse prescribers. Nurse Prescribing. 2007;5(6):251–255
- . Independent extended and supplementary nurse prescribing practice in the UK: A national questionnaire survey. International Journal of Nursing Studies. 2007;44(7):1093–1101
- Davenport, C. (2004) Analysis of PDAs in nursing: Benefits and barriers. (Accessed on 28/05/2008). Available at: www.pdacortex.com/Analysis_PDAs_Nursing.htm.
- . National progress on nurse practitioner numbers. The Nurse Practitioner Series. 2007;2(1):33–37
- . Nurses’ confidence and experience in using information technology. Australian Journal of Advanced Nursing. 2008;25(3):23–35
- . 2004 AANP national nurse practitioner sample survey. Part II. Nurse practitioner prescribing. Journal of the American Academy of Nurse Practitioners. 2005;17(12):506–511
- . Handheld computers in nursing education: A PDA pilot project. Journal of Nursing Education. 2008;47(2):74–77
- . Even techno-phobic NPs can use PDAs. The Nurse Practitioner. 2006;31(7):48–52
- . Evaluating nurse prescribers’ education and continuing professional development for independent prescribing practice: Findings from a national survey in England. Nurse Education Today. 2007;27(7):685–696
- . The way to the future. The Nurse Practitioner Series. 2007;2(1):38–42
- . NPs face challenges in the U.S. and the UK. The Nurse Practitioner. 2007;32(7):25–29
- . The past, present and future of nurse prescribing in the United States. Nurse Prescribing. 2003;1(4):170–174
- . After forty years. Journal of American Academy of Nurse Practitioners. 2005;17(1):913
PII: S1322-7696(08)00064-4
doi:10.1016/j.colegn.2008.10.001
Crown Copyright © 2008. Published by Elsevier Inc. All rights reserved.